REV-18-3608Miami Shores Village RECEIVED
building Department DEC 06 2018
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949 �
FBC 20 i� -
BUILDING
Master Permit No. ;qc
PERMIT APPLICATION
Sub Permit No._�l 1,� -340G6
❑BUILDING ❑ ELECTRIC''
❑`ROOFING
❑ REVISION ❑ EXTENSION ❑RENEWAL
iJ
❑PLUMBING MECHANICAL
❑PUBLIC WORKS
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
;, ,. V I "'
,
CONTRACTOR , DRAWINGS
JOB ADDRESS: iU 79
6, /—
W
'City: 5 o*0 , V `Miami Shores ?` 4 R • 7
, CountJ. ?
a ; `Miami Dade x¢'.` Zip �i3
,
:Folio Parcel#•
.. • At _ i
. r w ' •
Is the.Building HistoricallyDesignafed:. Yes t r %.ENO • '
OccuparicyType .:���w.°�- � t�
, �=.:Load:. Cons i n Ty e:
„�'•a F zt a'�!
� �. � . Flood Zone � ' BFE: " FFE: � '� •.
/�('i(�
Y'
OWNER: Name (Fee Simple Titleholder):
!� L
l�Q /V�,( le Phone#:
Address:
City: _ State:
Zip:
Tenant/Lessei £'`) ' `'
. " `
" Phone#:'
.e1Name:
//'
Ema\o
4 r1 \ !!? +
V�� q �•
V •ice �� `• 'I .. ' :11 'l i
l �� •
�
CONTRACTOR: Company Name:
(/- A�/Z ���i %/ f�Ri/A�', � NC. Phone#:605) 51176--57f�3,
Address: le g eld ;51
ZY
City: kL d k" j
State: rZ,
Qualifier Name: ,aj>
Z:k ii• l C(
Phone#: (060
State Certification or Registration #: C—A n %`g /.`�i 62Z
Certificate of Competency #:
DESIGNER: Architect/Engineer:
Phone#:
Address:
City: State: Zip:
Value of WoEk 10 fps r �,.�a Square/ in6Sr F9ot� of V(Is�rk:
-
fYE tr rr
Type of work: ice']'ff�'ition {:=11te�ation ❑New Zr
~� ❑Repair/,Replace ❑ Demolition
Description bfW rk:'� '' z'„ ra"v e
Specify color of color thru tile:
• Permit Fee!$ • CF $- Q ., 6 G . CO/CC $
Submittal•Fee$ •t F � • � F Y � -
Scanning Fee $ -HS " Cif Radon Fee $ 2— G. DBPR $ 2 • 2 Notary $
Technology Fee $ - Training/Education Fee Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $I
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address ~'` b^ 1 �,
City ° State Zip
Mortgage Lender's Name (if applicable) n- 7�+-�cir rY�) q ��}, �•(3��� [}s t - Y �;�+y{
Mortgage Lender's Addres'O 4
City �, State--h Zip x fq . #' ti j #
Application is hereby `made to`obfain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced, prior, to the issuanceof-a permit and that all -work will be performed to meet theistandards-of all laws regulating
construction in this jurisdiction. I understand that a separate pee'mit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS,.HEATERS, TANKS, AIR CONDITIONERS, ETC..... } ,
<L t. t�._. � ',,--";tla -� �,. � .+; `� l 1f.hS � i} "r � ,<' -E 1µ
OWNER'S'AFFIDAVIT: I certify that all the foregoing itiformation is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning. a
"WARNING, TO OWNER: YOUR FAILURE TO RECORD, A, NOTICE.OF COMMENCEMENT_ MAY
RESULT IN -YOUR PAYING, TWICE: FOR� IMPROVEMENTS JOYOUR_PROPERTY. IF YOU -INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY. BEFORE_ RECORDING
YOUR NOTICE OF COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of Eommencemenfand'consirucfion lien lacy brochure will be delivered to the person
whose property is subject to duachmenL_Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. !n the absence of such posted notice, the
inspecfibdwill not be approved and a reinspection fee will he charged. ,
f �
Signature` 'Signature`
or AGENT _- - _.CONTRACTOR
The foregoinginstrument was acknowledged before me this- - -- The foregoing instrument was acknowledged 'before -me this
day'of - 201 by,--�-- H day of - 1�� Ce � 20 � by V
�2(
i a <.rt*.,.': . ; r �`Z de Vs Q, 'a J Jeri,
�l{� r /� d+i dDh e , who ersonally kriow��'to ` ' _ 10544M . R , who is�ersonally know to
(I
me'or who'has' produced as me or who has produced-"- as
identification and `who did take an oatlki E F ij� -identification and who did take'an oath. `
"���V9�yO�i''
NOTARY'PUBLIC:-_ _,
_ ._
NOTARY
PUBLIC:
. 11OW i PiNk - Still of Florida
* ' • • * _
� ,; Commission `* FF� 9778682020
Sign:
-
Sign:
/ _ - _ w omm
s
Print: -
NA
-Print--
Seal: _ ___.
_ i�i.;a4tc_ st��d`
Seal:
APPROVED BY-� - Ptafl"s Examinef - Zoning
_ _ _� -- ,. - - � _, nci.t lt.al .�'Z�;Zi ;i =:T __- ---- - _- __ . •.�;' 'i al.ti.,r'�3�
Structural Review— -
Clerk
_ , .4, -, f 33 9 it,7
(116ised02/24/2014) T s . s